Medicare Program Integrity Manual
Chapter 6 - Intermediary MR Guidelines for Specific Services
Table of Contents
(Rev. 74, 04-23-04)
6.3--Medical Review of Certification and Recertification of Residents in SNFs
The Medicare conditions of payment require a physician certification and (when specified) recertification for SNF services. This requirement is explicitly stated in �1814(a)(2) of the Social Security Act. 42 CFR 424.20 details the required contents of the certification and re-certifications and 42 CFR 424.11 specifies that "no specific procedures or forms are required for certification and recertification statements," and that "the provider may adopt any method that permits verification. The certification and recertification statements may be entered on forms, notes, or records that the appropriate individual signs, or on a special separate form." Further, 42 CFR �424.11(c) states, "If that information is contained in other provider records, such as physicians' progress notes, it need not be repeated. It will suffice for the statement to indicate where the information is to be found." Recent decisions by administrative law judges, that CMS believes are fully consistent with law and regulations, reinforce the need for fiscal intermediaries to consider documentation in the beneficiary's medical record beyond a discrete certification or recertification form to determine if the required elements for certification are present.
Claim denials should be made for failure to comply with the certification or re-certification requirements as described in 42 CFR 424.20. Claim denials may not be made for failure to use a certification form or particular format.
Chapter 6 - Intermediary MR Guidelines for Specific Services
Table of Contents
(Rev. 74, 04-23-04)
6.3--Medical Review of Certification and Recertification of Residents in SNFs
6.3--Medical Review of Certification and Recertification of Residents in SNFs
(Rev. 74, 04-23-04)The Medicare conditions of payment require a physician certification and (when specified) recertification for SNF services. This requirement is explicitly stated in �1814(a)(2) of the Social Security Act. 42 CFR 424.20 details the required contents of the certification and re-certifications and 42 CFR 424.11 specifies that "no specific procedures or forms are required for certification and recertification statements," and that "the provider may adopt any method that permits verification. The certification and recertification statements may be entered on forms, notes, or records that the appropriate individual signs, or on a special separate form." Further, 42 CFR �424.11(c) states, "If that information is contained in other provider records, such as physicians' progress notes, it need not be repeated. It will suffice for the statement to indicate where the information is to be found." Recent decisions by administrative law judges, that CMS believes are fully consistent with law and regulations, reinforce the need for fiscal intermediaries to consider documentation in the beneficiary's medical record beyond a discrete certification or recertification form to determine if the required elements for certification are present.
Claim denials should be made for failure to comply with the certification or re-certification requirements as described in 42 CFR 424.20. Claim denials may not be made for failure to use a certification form or particular format.
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